Monthly Archives: May 2015

In my addendum to Marvin’s blog last week I referenced Jack Nicholson in One Flew Over the Cuckoo’s Nest. I’m sure everybody got the reference. Some of those scenes are burned into the collective imagination. And I was a fan of both Ken Kesey’s novel and the movie. I say ‘was’, because as great as Nicholson’s performance, as great as Milos Forman’s direction, and Louise Fletcher’s acting, the movie may have played a minor role in the demise of the Mental Illness treatment system of North America and a return to incarceration in jails and prisons for thousands of the mentally ill, to say nothing of an unwarranted negative public reaction to ECT. At least unwarranted since it has become more selectively and carefully used to treat only patients with severe illness not responding to medication.

The novel rose out of Mr. Kesey’s part time work as an attendant on the night shift of a Veteran’s Hospital, while taking part in a CIA sponsored experiment with psychedelic, hallucinogenic drugs, in the late 1950’s.

Movies are magic, and they play fast and loose with the truth. In the sound and fury of them, in our vicarious pleasure of escaping our bonds, seeking revenge, getting back the man or woman of our dreams, and saving the world, we often miss a few nuances and incongruities.

Randle McMurphy does embody the free rebellious rule-breaking individual confronting oppressive institutional authority as personified by Nurse Rached. And the movie makes us root for him and hate Nurse Rached. Her ultimate weapons being ECT and Lobotomy.

Now there certainly is some truth to those big overcrowded wards of large mental hospitals being run by nurses whose prime directive was to keep everything peaceful, under control, with a modicum of care and nurturing on the side. And the doctor often was, as described by sociologists, the absent father whose power could be invoked by the nurses, as in “You just wait until your father gets home.”

But here are some of the nuances in that film that slip by us: All but a couple of the patients on that ward are voluntary and could leave any time they wanted. And McMurphy, well, he is a charming psychopath, and he has faked insanity so he could be transferred to that hospital from a prison. His most recent conviction is for statutory rape with his defense being, “She came on to me.” That would imply that McMurphy had sex with a 13 or 14 year-old child at the time the book was written.

Our attitudes have shifted a little since that film was made. Today McMurphy might be charged with “sexual assault” “rape of a minor” “sexual molestation of a minor”. He would be placed on a sexual offense registry, and the public and our courts would show him little sympathy. And, I suspect, that if I were asked to provide a psychiatric evaluation of McMurphy, I would be telling the court that he is high risk to re-offend.

On the other hand, if any actor could make us root for a pedophile it would be Jack Nicholson in his prime.

This year, the American Psychiatric Association (APA) is having its annual conference in Toronto starting May 16 and, again, they are being picketed. While most Canadians are enjoying the first long weekend of summer opening cottages, having picnics, planting their gardens and enjoying the fireworks –a hold over from our colonial heritage celebrating the birthday of Queen Victoria – anti-psychiatrists are marching.

Strangely, this is not an unusual event. The APA is the only medical organization that is regularly picketed and this year, opponents of electroconvulsive shock therapy (ECT), are gathering at Toronto’s City Hall Square to march across the street to the Sheraton Hotel. This is a rather curious locale since the conference is at the Metro Convention Centre about a mile from the hotel.

According to the facebook manifesto “this psychiatric organization constantly deceives, minimizes and generally lies about the devastating trauma, permanent memory loss and brain damage caused by electroshock. It actively promotes ECT and holds continuing education courses, funded by Big Pharma, at all its annual meetings.”

It goes on to say that “In its 2007 official policy position statement, the APA claims, “Electroconvulsive therapy is a safe and effective evidence-based medical treatment. ECT is endorsed by the APA when administered by properly qualified psychiatrists for appropriately selected patients.”

The APA and The National Institute for Health and Care Excellence (NICE) in the UK do not endorse the use of ECT based on a whim or without proper evidence and they do not recommend it for everyone. ECT is used for rapid improvement, in the short term, of these symptoms

Severe depressive illness or refractory depression.

Catatonia.

A prolonged or severe episode of mania.

It should only be used if other treatment options have failed or the condition is potentially life-threatening (eg, personal distress, social impairment or high suicide risk).

A metaanalysis published in 2014 that compared ECT with the newer transcranial magnetic stimulation concluded that ECT is the leading therapeutic modality for patients with treatment resistant depression.

ECT can be helpful! Now I would join the protesters if psychiatrists dragged unsuspecting patients out of their hospital beds, hustled them down the hall to a room where they attached electrodes to their heads and zapped them with electricity.

But this does not happen!

There is this thing know as informed consent and every patient, or their substitute decision maker if they are not competent, signs one. Before a doctor can treat – be it ECT or pumping toxic chemicals into the body to rid it of cancer – the patient must understand the potential risks and benefits of the treatment before consenting to it. With ECT, the patient is in extreme distress, nothing else has helped and they are desperate for relief.

For some stranger like those marching at the Sheraton Hotel in Toronto to think they can decide what is good or not good for a patient takes an enormous amount of chutzpah.

A Personal View of ECT from Dr David Laing Dawson

The year was 1969. I was a psychiatric resident in a new open-door nicely appointed psychiatric ward and I didn’t think much of ECT. It had been overused in the past, but all specialties of medicine have a history of finding a treatment that works (finally!) and then over-using it, from antibiotics to every kind of surgery. Still, it just felt wrong to induce a seizure, a convulsion, to fix a mental disorder, especially when we had no clue why it actually worked.

So I avoided using ECT, and had managed without it for about a year and a half.

And then a man in his twenties was admitted to my care. He was thin, almost emaciated, and not talking. He had been living in a small room in the back of his parents’ downtown apartment and had gradually ceased to look after himself or get out of bed. Now he lay on his back in a hospital bed. He did not speak. He made no eye contact.

I sat beside him and talked. Nothing. Over time I gave him several medications and then withdrew them. Nothing. I hauled him out of bed each day for a week, and, holding his arm, walked him around the hospital ward. Nothing. We could keep him hydrated with some nutrients but he was still not eating.

So it came down to ECT. Six treatments. His mood brightened. He made eye contact. He ate. He talked to me. He remained my patient for a few months, moving to the day hospital and then outpatients. Because he now talked with me I could figure out what medications might keep him well.

And for five years after that, every year, I received a Christmas card from him thanking me.

And today, perhaps with thanks to Jack Nicholson, of all the treatments and procedures administered by modern medicine for serious illness, ECT is one of the safest, most effective, and very carefully restricted and monitored.

It started with a bout of shingles, then a post-herpetic labyrinthitis, and then I got the flu, or at least a very nasty virus within that family of viruses. Into my chest, and then my bowels, fever and chills, exhaustion, anxiety, headache. Could not take solids for four days. On the eleventh day my wife insisted I see the on call doctor at the clinic. They operate out of little rabbit warren closets these days, computer and keyboard on hand.

He was a pleasant young man, asked appropriate questions, examined my chest, looked down my throat, in my ears. He actually asked what I hoped to get from this appointment. I said probably a chest x-ray is in order, and maybe antibiotics. He smiled wanly and said “We’ll see about antibiotics after the chest x-ray.”

So we drove from there to a new building twenty miles away. We parked in front. It is a growing part of town with a big new Grocery Store next door. The entrance hall to this building, number 35, turned out to be lushly appointed, with a pharmacy to the right and a naturopathic clinic to the left. Signage was poor but we eventually figured out the imaging equipment, the x-ray department was in the basement, down one level in a small elevator.

But before getting to the elevator I looked in the naturopathic clinic. It was inviting. A sign outside asked, “Are you feeling unwell.” “Yes”, I said to myself. “Yes. Good Christ yes.”

The rest of the wording promised they’d have something that would surely make me feel better. Come in. Two women stood behind a counter. Soft lighting. Multiple shelves of jars, canisters, packages waited to satisfy my body’s deficiencies, my every need. I wanted to feel better. I wanted to see a very friendly sympathetic person who would tell me what was wrong with me, and then assure me that all I needed was a little of this potion or that. It would make me feel so much better.

In the basement the Imaging Department was also clean and new, but rather barren. The pleasant technician fetched me promptly and led me to that new age machine in another barren room. She put me through the paces: breathe deep, hold, let it out, good. And sent me back to wait. The radiologist would take a quick look; they’d call the family doctor, and then they’d tell me if I could go home or visit a pharmacy or proceed to hospital. It took only about ten minutes, and the pleasant technician called from the reception window to tell me that I could go home.

And home we went, first walking past that naturopathic clinic and its sign that beckoned: Feeling unwell?

Yes, dammit, yes.

Would you like someone telling you she knows what’s wrong and what would make it right?

Yes, dammit, yes.

I didn’t go in.

And we drove home knowing that at least a.) Nothing showed in my chest x-ray indicating imminent cardiac or respiratory failure. And b.) The doc was not going to prescribe antibiotics for what is undoubtedly a virus.

There it was again. The local paper reporting on homelessness, reporting on the results of a survey of over 400 homeless people in our city. All very nicely written and laid out. The number of homeless people who have been the victims of violence; the number who struggle with addictions. And the over 80% who suffer from “mental health issues.”

Dictionary definitions of the word ‘issue’ include:

“An important topic or problem for debate or discussion” – the operative portion of that definition being “for debate or discussion.”

Now I understand that how we describe or name something may shift and change over time, often for good reason, often not. We no longer use the word ‘retarded’ to describe someone who has less than average intellectual capacity. It is a word that accrued a lot of baggage through the years, and became a schoolyard epithet, implying, at least in the vernacular of teenagers, something like “willful stupidity”, or “in bad taste.”

But euphemisms often creep into our vocabulary to hide the truth, or to reduce the sting of truth. Sometimes the euphemisms are simply more polite (‘disability’ may become ‘special needs’); sometimes they are obfuscations with only a limited reference to the original activity, problem, or thing (‘illness’ becomes ‘issue’), and sometimes they are softer vague words chosen to hide the reality of the action or intention of our governments, bureaucrats, and military, and sometimes they are even, a la George Orwell, antonyms of the word that would actually reveal the truth.

I don’t know how the word ‘issue’ became the mot du jour, sometimes even added as a totally unnecessary noun. As in ‘he has addiction issues’ instead of ‘he is addicted’. I suspect it is related to the actual meaning of ‘issue’, (a topic open to debate), and by calling mental illness an issue we are placating the deniers of mental illness and we are reducing it to an abstraction, a topic for discussion and debate, rather than a reality in our midst, and often the actual cause of homelessness.

Even if, reasonably, we want to reserve the words ‘disease, illness, and disorder’ for only severe forms of this reality, this plight, we still have other words to chose from that do not imply a debatable abstract: ‘problem, difficulty, trouble, worry’. We might even say “mental health concerns, including mental illness”.

But let’s stop with the “issue” when we are naming or describing a painful reality.